Editorial

Welcome to this special edition of Prosthetics and Orthotics International on the International Classification of Functioning, Disability and Health, commonly referred to simply as the ICF. The ICF is a classification of health and health-related domains. ¹ The classification is divided into two parts: functioning and disability, and contextual factors, with each part having two components. The two components of functioning and disability are: body functions and structures, and activities and participation. Contextual factors also have two components: environment and personal factors. Personal factors are not coded in the ICF.

The 191 World Health Organization (WHO) Member States officially endorsed the ICF on 22 May 2001 in the 54th World Health Assembly. The ICF has been translated into numerous languages and is the framework set by the WHO for measuring health and disability at both individual and population levels. The ICF was endorsed for use in the Member States as the international standard to describe and measure health and disability. Use of the ICF has become the foundation for disability data collection to support the UN Convention on the Rights of Persons with Disabilities. ² Recently, the adoption of the ICF has been recommended as a universal framework for disability data collection in the World Report on Disability. ³ The WHO has suggested that the ICF can be used in five areas related to health and human functioning – the clinical setting, research, education, as a statistical tool and in the social policy setting.

There has been significant work in various settings, including health and associated professions to introduce the ICF into everyday clinical practice. The ICF is increasingly used and is developing as a common language across health disciplines and among the numerous groups interested in understanding, quantifying, preventing and treating activity and participation restrictions in individuals with disability. These developments are in line with the aims of the ICF, namely to:

provide a scientific basis for understanding and studying health and health-related states, outcomes and determinants;

establish a common language for describing health and health-related states in order to improve communication between different users, such as healthcare workers, researchers, policy makers and the public including people with disabilities;

permit comparison of data across countries, healthcare disciplines, services and time; and

provide a systematic coding scheme for health information systems.

The patient is the central focus of the classification with all elements of the classification referring to the effect the individual categories have on the patient

The ICF puts the notions of ‘health’ and ‘disability’ in a new light. It acknowledges that every human being can experience a decrement in health and thereby experience some degree of disability. Disability is not something that only happens to a minority of humanity. The ICF thus ‘mainstreams’ the experience of disability and recognises it as a universal human experience. By shifting the focus from cause to impact it places all health conditions on an equal footing allowing them to be compared using a common metric – the ruler of health and disability. Furthermore the ICF takes into account the social aspects of disability and does not see disability only as a ‘medical' or ‘biological' dysfunction. By including contextual factors, in which environmental factors are listed, the ICF records the impact of environment on a person's function.

This special issue of Prosthetics and Orthotics International is the first stock take within the broader groups of professions involved with the International Society for Prosthetics and Orthotics. It brings together some of the current research and work incorporating the ICF into the areas of orthotics and prosthetics. It provides valuable insights into the broad range of applications of the ICF in practice in the fields of prosthetics and orthotics and also highlights that there is still considerable work outstanding to achieve a uniformly applicable standard of description and quantification of restrictions, limitation and interaction of environmental factors in individuals with a disability.

The paper ‘Systematic review of concepts measured in individuals with lower limb amputation using the International Classification of Functioning, Disability and Health as a reference’ ⁴ demonstrates that the vast majority of all concepts identified in outcome measurements used for persons following an amputation can be mapped to the ICF. This confirms what was previously published that the ICF proved to be a highly comprehensive classification covering virtually all aspects of the patient experience, ⁵ and suggests that there is widespread potential for broader use of the ICF in the prosthetic and orthotics community and their patients.

The impact of disability has been partially described over many years in a number of publications. Using the ICF as a framework for outlining environmental barriers, activity limitations and participation restrictions enables more detailed descriptions for national and international comparisons. The paper by Gallagher is a novel approach to better understanding the restrictions, limitations and environmental barriers as it uses data from the Irish National Physical and Sensory Disability database. While the data collection is not complete, the paper demonstrates that analysis of data from large disability databases enhances the understanding of the effect of various disabilities on patients. Analysis of data from national databases and inclusion of ICF categories in census data collection can assist to develop a clearer understanding of the many facets of functional consequences of disability and illness. ⁶

The ICF was developed as a classification, and it has become common practice to map outcome tools against the various domains and categories of the ICF. Mapping of outcome tools facilitates comparisons between various outcome tools and further clarifies the nature of limitations and restrictions. The Southampton Hand Assessment Procedure is such an outcome tool and the paper in this issues is an early attempt to tie together clinical trials of assistive devices with the ICF classification and terminology. In other areas of healthcare, ICF terminology has already become standard while in prosthetics and orthotics it is still under development. ⁷

The potential for expanding the applicability of the ICF beyond the purpose of a classification is the main focus of a paper examining the feasibility of using an ICF checklist as an outcome instrument. If the ICF can be utilised as an outcome tool as well as a classification tool this would considerably increase its appeal to the clinicians who are interested not just in classifying their patients but, in particular, of demonstrating improvements secondary to interventions as measured by reliable outcome instruments. It will be interesting to monitor further developments of the ICF as a potential outcome measure. ⁸

Utilisation of the ICF in daily clinical practice is frequently discussed in the literature, but there are few publications outlining such use. The paper by Burger demonstrates that the ICF can be used in daily clinical practice in an outpatient setting and that it is both sensitive and useful in describing the functional status of patients requiring prostheses or orthoses, as well as the effects of such devices. Further work will be required, however, to develop lists of categories which can be routinely used in various settings. ⁹

A paper emphasizing the importance of establishing a more solid evidence base for clinical practice in the field of orthotics demonstrates how the ICF can facilitate uniformity of data collection both for clinical trials and clinical practice. The development and use of an ICF Core Set of information collected for each orthotic device prescribed would allow a more standardized approach and assist in ensuring that minimum standards are applied in the process. This paper also demonstrates that using the broad classification enhances the combination of intervention-related and patient important concepts, in line with current patient expectations. ¹⁰

A discussion paper based on a prescription guideline for assistive devices emphasises some of the deficiencies of the ICF, particularly in the environmental categories. The environmental factors lack specificity and detailed description is not possible. However, many of the data items required for prescription of assistive devices could be coded using the ICF categories. ¹¹

The utility of the ICF in the training of health professionals and in clinical practice is outlined in a paper describing the ICF-based training programme for medical residents in rehabilitation medicine. The approach outlined does not need to be restricted to the medical profession but can be applied by all health professionals and can facilitate comprehensive assessments. Assessing the patient from the perspective of the disease model, as well as their function, activity and participation levels and environmental perspective is a fundamental component of rehabilitation medicine as it is essential to have a comprehensive understanding of the patient in their psychosocial environment. ¹²

I am sure that this special issue of Prosthetics and Orthotics International will give all readers a clearer understanding of the ICF, its usefulness in clinical practice and some of its limitations. I hope that it will stimulate further research and willingness to implement using the ICF in the clinical setting.